Provider Demographics
NPI:1447672266
Name:WAY, KRISTINE (LICSW)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:WAY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 E COURT ST STE A
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39201-5004
Mailing Address - Country:US
Mailing Address - Phone:410-336-9303
Mailing Address - Fax:
Practice Address - Street 1:623 E COURT ST STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39201-5004
Practice Address - Country:US
Practice Address - Phone:410-336-9303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-14
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500784371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical